The Maternal Fetal Triage Index

Transcription

1 The Maternal Fetal Triage Index Catherine Ruhl, MS, CNM Director, Women s Health Programs AWHONN Disclosures No commercial support or sponsorship was received for this presentation Presenter reports no relevant financial or commercial conflicts related to this AWHONN 2 1

2 Objectives 1. Discuss the concept of triage as a nursing role and responsibility 2. Describe how a standardized approach to obstetric triage can improve processes and outcomes 3. Explain the development and use of AWHONN s Maternal Fetal Triage Index AWHONN 3 Quality Triage Care Should women have to wait to be triaged? Do you have a standardized approach to women who present with hypertension or other non-labor AWHONN 4 2

3 Three women arrive on a holiday eve Woman #1 Woman#2 Woman#3 G3P2002 G2P1001 G1P0 28 yo 22 yo 18 yo 39.0 wks 29.2 wks 38 wks Ctx q 2-3 FM c/o HA BOWI No labor sx no ctx Holding abdomen w/ ctx Who does RN see first? Where do the others AWHONN 5 Triage is a AWHONN 6 3

4 Triage is not a AWHONN 7 AWHONN s Triage Initiative Re-define OB triage Reaffirm obstetric triage as a nursing role Improve quality of triage nursing care through standardization of acuity classification (the MFTI) Improve education for nurses about triage Test a triage quality AWHONN 8 4

5 AWHONN s Definition of Obstetric Triage Obstetric triage is the brief, thorough and systematic maternal and fetal assessment performed when a pregnant woman presents for care, to determine priority for full AWHONN 9 AWHONN s Definition of Obstetric Triage Obstetric triage is performed by nurses. Triage is followed by the complete evaluation of woman and fetus by Qualified Medical Personnel (MD, CNM, NP, or RN who meets AWHONN 10 5

6 Triage and Evaluation Assessment (RN) Prioritization Mobilization Escalation (RN) Evaluation (provider or RN/provider) Disposition (Provider) Mobilization: process of moving people or resources Escalation: intensifying AWHONN 11 Comparing ED and OB triage Emergency Department Triage refers to the brief RN assessment to determine the urgency for evaluation Birth units Triage (pre-mfti) refers to RN s initial assessment and provider evaluation Occurs in a triage intake area May occur on a separate unit or in the LDR Nationally-accepted acuity classification tool determines priority for evaluation Prior to MFTI, no national standard for assigning priority for AWHONN 12 6

7 Comparing ED and OB triage Emergency Department Triage RN qualifications: standardized course and orientation Birth units Triage RN qualifications? Orientation to triage? Triage RN responsibilities: help out in ED when no triages Triage RN duties: continue to care for pt during eval and obs, may be charge nurse, may have admitted pt AWHONN 13 Comparing ED and OB triage Emergency Department Value of triage RN- The most important nurse in the ED even more important than the charge nurse (NH nurse) Why so valuable? First line of defense First to identify problems First to mobilize staff and resources Birth units Value of triage RN: Not a well-defined role until now so more challenging to establish value Why so valuable? First line of defense First to identify problems First to mobilize staff and AWHONN 14 7

8 ENA s triage qualifications ENA supports use of a reliable, valid 5-level triage scale Minimum one year experience as an emergency nurse Complete a comprehensive course and clinical orientation Ongoing competency validation Emergency Nurses Association. (2017). Triage qualifications and AWHONN 15 Where do you triage? How many have an intake area for triage? How many have a separate area or rooms for triage and evaluation? How many triage in the AWHONN 16 8

9 Do you use a triage acuity tool? Photo used with permission from Jenn AWHONN 17 Does your main ED use a triage acuity index? Why should a hospitalized pregnant woman receive a different standard of care than a nonpregnant AWHONN 18 9

10 Triage Assessment Elements Chief complaint* Vital signs/ FHR Fetal movement Ctx/LOF/Bleeding Pain rating (non-labor complaint) Coping with labor Mental status Pregnancy history Past OB history Past med/surg history/ allergies Social history *Infectious disease exposure if AWHONN 19 Why standardize triage? 1. Improve nurse-provider communication 2. Decrease errors/potential liability 3. Standardize education on triage 4. Standardize triage assessment 5. Mobilize resources efficiently 6. Obtain valuable data First come First served! pzgt1zphzg These reasons apply to OB units of every size, large and small 2014 AWHONN 10

11 Triage and Liability Failure to triage and evaluate a woman appropriately 2nd most common allegation* 21% of professional liability claims* Case example Failure of triage nurse to present an accurate picture of the case to the attending *Review of 100 cases of alleged obstetric liability, Muraskas et al., AWHONN 21 Triage and Liability Failure to transport a woman to a tertiary center when indicated 4th most common allegation* 11% of professional liability claims* Case examples Extreme prematurity, complicated twin gestations, triplets or higher orders, known congenital anomalies *Review of 100 cases of alleged obstetric liability, Muraskas et al., AWHONN 22 11

12 Areas of Risk in OB Triage Timeliness of assessment response from OB Providers and consultants, transfer of high risk patients to an appropriate facility equipped to provide the required level of specialized care. (Angelini, 2013). Serious reportable events involved fetal deaths related to timeliness of triage, evaluation and intervention 2013 AWHONN 23 OB Triage Education Trinity Health System reports in 2015: < 5% of OB RN Directors using an acuity tool OB triage. None of the 35 birthing hospitals use a standardized education program to orient RNs to the role of the OB triage nurse. Majority of hospitals assign RNs to work in the triage area after working a designated period of time in labor and delivery; usually a minimum of one year. Lack of objective competency assessment 2013 AWHONN 24 12

13 Classifying acuity gives you valuable data! 1. Acuity trends 2. Track time from presentation until triage complete, time to evaluation per priority level 3. Track patient LOS in triage/eval unit and overall flow based on acuity 4. Track adequacy of nurse staffing in triage r/t acuity 5. Measure women s satisfaction with triage and evaluation 6. Track decrease in new reportable events r/t triage and evaluation 2014 AWHONN The gestation of the Maternal Fetal Triage Index (MFTI) 1. Expert task force drafted an acuity tool 2. Content validation (RN, CNM, MD) 3. Interrater reliability 4. Educational module testing Over 100 nurses, physicians and midwives contributed to developing the AWHONN Ruhl, Scheich, Onokpise & Bingham,

14 Foundational acuity indexes The Emergency Severity Index Fla Hospital OB Triage Tool Agency for Healthcare Research and Quality, 2012 Paisley, Wallace & DuRant, 2011 AWHONN s Maternal Fetal Triage Index Five levels of acuity Key questions on the left Includes need to transfer to higher level of AWHONN Exemplary clinical conditions on the right Vital signs are suggested values-use FIRST set. Ruhl, Scheich, Onokpise & Bingham,

15 Stat (Priority 1) (abbreviated version) Does the woman or fetus have STAT/PRIORITY 1 vital signs? or Does the woman or fetus require immediate lifesaving intervention? or Is birth imminent? *Vital signs are suggested values 2014 AWHONN Abnormal Vital Signs Maternal HR <40 or >130 Apneic Sp02 <93% SBP 160 or DBP 110 or <60/palpable No FHR FHR <110 bpm for >60 seconds Lifesaving interventions o Maternal o Fetal Imminent birth Urgent (Priority 2) (abbreviated version) Does the woman or fetus have URGENT/PRIORITY 2 vital signs? OR Is the woman in severe pain unrelated to contractions? OR Is this a high-risk situation? OR Will this woman and/or newborn require a higher level of care? *Vitals signs are suggested values 2014 AWHONN Abnormal Vital Signs* Maternal HR >120 or <50, Temperature F, (38.3 C), R >26 or <12, Sp02 <95%, SBP 140 or DBP 90, symptomatic or <80/40, repeated FHR >160 bpm for >60 seconds; decelerations Severe Pain: (not ctx) 7 on a 0-10 pain scale 15

16 Urgent (Priority 2) (abbreviated version) Is this a high-risk situation? 2014 AWHONN Prompt (Priority 3) (abbreviated version) Does the woman or fetus have PROMPT/PRIORITY 3 vital signs? Does the woman require prompt attention? Abnormal Vital Signs Temperature >100.4 F, 38.0 C1, SBP 140 or DBP 90, asymptomatic Prompt Attention such as: Signs of active labor 34 weeks c/o early labor signs and/or c/o SROM/leaking /7 weeks 34 weeks planned, elective, repeat cesarean with regular Woman is not coping with labor per the Coping with Labor Algorithm V2 16

17 Non-urgent (Priority 4) Does the woman have a complaint that is non-urgent? Non-urgent attention such as: 37 weeks early labor signs and/or c/o SROM/leaking Non-urgent symptoms may include: common discomforts of pregnancy, vaginal discharge, constipation, ligament pain, nausea, anxiety. Scheduled/Requesting (Priority 5) Is the woman requesting a service and she has no complaint? OR Does the woman have a scheduled procedure with no complaint? Woman Requesting a Service, such as: Prescription refill Outpatient service that was missed Scheduled Procedure Any event or procedure scheduled formally or informally with the unit before the patient s arrival, when the patient has no complaint. 17

18 What RNs are saying about the MFTI I love the MFTI. It really prompts you to be aware of what priority your patients are. The MFTI is great and easy to use! I used to have difficulty trying to determine who needed my attention first. I really like the vital signs clearly listed as part of the MFTI. It really helps in our timely treatment of patients with hypertensive emergency. Photo used with permission from Brianne Fallon, RN, Shawnee Mission MC, Shawnee Mission, KS Why is the MFTI unique? Mom AND baby The only national obstetric triage acuity tool for the entirety of pregnancy Multidisciplinary input Rigorous development by AWHONN 18

19 Hospital-Based Triage of Obstetric Patients ACOG Committee Opinion #667 July, 2016 Recently developed, validated algorithms such as the Association of Women s Health, Obstetric and Neonatal Nurses Maternal Fetal Triage Index could serve as templates for use in individual hospital 37 How can the MFTI improve care? Not missing abnormal presenting vital signs Early identification of need to transfer to higher level of care Not missing scheduled women who have complaints Proper attention to non-ctx pain women not coping with labor decreased fetal movement possible preterm AWHONN 38 19

20 What is NOT in the MFTI? Cervical dilation Necessity of a FHR strip Time to provider evaluation based on priority level Frequency of RN reassessment while awaiting evaluation Not a diagnostic AWHONN 39 Clinical Judgment The MFTI guides clinical decision-making Some clinical presentations may not meet the exact criteria described in the MFTI Prioritize to the higher level when there is a lack of clarity The MFTI can protect from cognitive bias 2014 AWHONN 20

21 Now it s your turn! Systematically assess the following cases always keeping in mind: Vital signs Pain rating for non-labor pain Coping/not coping if in labor Fetal movement? 2013 AWHONN 41 Three triaged women on a holiday eve Woman #1 Woman#2 Woman#3 G3P2002 G2P1001 G1P0 28 yo 22 yo 18 yo 39.0 wks 29.2 wks 38 wks Ctx q 2-3 FM c/o HA, 5/10 pain BOWI No labor sx BP 126/72, FHR WNL Holding abd w/ ctx VS, FHR WNL doppler VS, FHR WNL Coping w/ ctx What are their MFTI priority levels? Which woman gets the one available AWHONN 42 21

22 Assign the MFTI Priority 18 yo G1P weeks Denies ctx, unsure if water broke, pain=0 Initial BP 146/74 Denies preeclampsia sx Repeat BP 10 min later- 130/72 Other VS and FHR WNL 2013 AWHONN 43 Assign the MFTI Priority 32 yo G2P weeks VS and FHR WNL States she doesn t feel ctx or tightening, active FM, no c/o Sent from office with short cervix, no ctx for further monitoring 2013 AWHONN 44 22

23 Assign the MFTI Priority for Ms. L 32 yo, G3P weeks c/o severe, constant upper abdominal pain (9/10), sweating c/o H/A (5/10), denies visual changes Says maybe mild ctx BP 144/88, P 122, R 20, T 98.9, FHR 150s There may be more than one reason for your AWHONN 45 Benefits of the MFTI for Ms. L Attention to abnormal vital sign (BP 144/88, pre-eclampsia sx, P 122) Attention to non-ctx pain (9/10) Timely evaluation Elimination of cognitive AWHONN 46 23

24 AWHONN s Perinatal Nursing Quality Measure on Triage The goal is that 100% of pregnant patients presenting to the labor and birth unit with a report of a real or perceived problem or an emergency condition will be triaged.within 10 minutes of arrival. Learn more at: cticeresources/02_perinatalqualitymeasures.htm 2014 AWHONN AWHONN s MFTI Communities Over 120 hospitals participating, 2016 and 2017 Peer support and AWHONN mentoring for implementation of the MFTI Integrated MFTI into EMR or used on paper Educated nursing staff with AWHONN s online, interactive MFTI AWHONN 48 24

25 Lessons from AWHONN s MFTI Communities 1. Educate nursing staff on triage/mfti 2. Form a steering committee-multidisciplinary 3. Identify shift champions 4. Educate providers grand rounds 5. Identify a location for triage, if needed 6. Implement the MFTI (paper or EMR)-trial 7. Audit to promote correct use of MFTI Conclusions to date: education well-received, implementing MFTI is catalyst for overall triage AWHONN 49 MFTI Community Chart Audits Most discrepancies in priority assignment placed woman at lower priority than MFTI indicated Abnormal vital signs Preterm ctx or LOF Decreased fetal movement Non-labor pain 7 or AWHONN 50 25

26 Quality Triage Care 1. No women waiting, untriaged 2. Classify all women s acuity 3. Implement standardized approach to triage, evaluation and AWHONN 51 Questions? For clinical questions about the MFTI contact Catherine Ruhl at cruhl@awhonn.org For questions about the MFTI educational module and implementation communities, contact Mitty Songer at msonger@awhonn.org 26